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Case Study

Complex needs coordination team (CoNeCT)

5 Minute Read


The challenge

Many organizations struggle to address the care needs of frequent emergency department (ED) users, who consume a disproportionate amount of resources. These are often polychronic, geriatric patients with common respiratory, cardiac, and renal conditions. While these patients may not need to be in care homes, they aren’t always connected with the right level of care.

The organization

North Metropolitan Health Service is a six-hospital health system in Perth, Western Australia, covering 950,000 patients.

The approach

North Metropolitan created a dedicated care coordination team, to bridge service gaps for patients who frequently present to the ED.

The result

North Metropolitan experienced a dramatic decrease in ED visits and hospital admissions. The team also decreased length of stay for target patients who are admitted.



North Metropolitan created CoNeCT, a program to support frequent ED users through a well-coordinated discharge strategy.

The CoNect program consists of three key elements:

  1. Care team. The CoNeCT team consists of care specialists who work together to create a comprehensive discharge plan. By addressing the medical and psychosocial needs of patients, ED visits are reduced.

  2. Patient identification. Patients can be referred to the program at any point along their care journey based on particular inclusion criteria. Entry points include the ED, acute care units, and primary care.

  3. Care planning. The program provides comprehensive and intensive care support. A snapshot of the patient journey along the CoNeCT program is outlined below.


Care planning reduces ED strain, has positive impact onpatients and providers. 

Patients enrolled in the CoNeCT program experience a dramatic decrease in ED visits. Additionally, these patients have decreased rates of admission and shorter lengths of stay when they are admitted.


Patients in active case load at any given time


Patients seen over three years of service


Reduction in acute length of stay, 2011-2012


Reduction in hospital admissions, 2011-2012


Reduction in ED presentations by CoNeCT
patients, 2011-2012 

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